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Summary

Hepatic encephalopathy (HE) has been shown to have a major impact on survival in patients with decompensated cirrhosis, however the effect of HE following TIPS placement on survival has not been clearly delineated. 304 patients who underwent TIPS placement for variceal hemorrhage or refractory ascites were retrospectively analyzed for the development of OHE within 3 months of TIPS placement, as defined by grade 2-4 HE according to the West Haven Criteria. Multivariate, time-dependent models were applied to assess the impact of early OHE, early-single OHE, and early recurrent OHE. The cumulative rate of OHE occurring within 3 months of TIPS was 27.6% (n=84) with a total of 149 episodes of OHE occurring within this population. Early-recurrent OHE (64.9%) was associated with a statistically significant higher rate of mortality than those without early-recurrent OHE (20.6%) (HR = 4.31; 95% CI: 2.64–7.06; P < .001). In the multivariate analysis, early-recurrent OHE (HR = 2.81; 95% CI: 1.67–4.73; P < .001), MELD score (HR = 1.16; 95% CI: 1.06–1.26; P = .001), age (HR = 1.04; 95% CI: 1.02–1.06; P < .001), and ascites (HR = 1.91; 95% CI: 1.04–3.53, P =.037) were associated independently with survival. Landmark and propensity score analysis confirmed that early-recurrent OHE remained a significant predictor of survival.

Figure 2 (a) Probability of survival in patients with and without early OHE. (b) Probability of survival in patients with and without early-single OHE. (c) Probability of survival in patients with and without early-recurrent OHE.

Commentary

This study provides valuable insight into a patient’s prognosis following the development of HE after TIPS. Previous research has debated the association between HE and mortality following TIPS, however the results of the present study further supports the conclusion that HE following TIPS is associated with increased mortality. The large sample size coupled with rigorous statistical analyses bolsters the results of this study. Patient’s that develop recurrent OHE within 3 months of TIPS have significantly poorer survival than those with only one occurrence of OHE. Given that 44% of patients who had a first OHE episode after a TIPS would experience recurrent OHE within 3 months, intense surveillance and therapy should be pursued during this time period. It should be noted that a majority of the patients in this study developed cirrhosis secondary to Hepatitis B (84%), so the results may not be completely generalizable to patients with other chronic liver disease.